Emergency Obstetric and Post Abortion Care

Overview of Emergency Obstetric
Care (EmOC) and
Post Abortion Care (PAC)
Towards Impact in Health
Workshop
Arusha, Tanzania
May 2-6, 2011
Learning Objectives
By the end of this session, participants will
be able to:
1. Explain the concept of EmOC
2. Name at least 4 direct obstetric
complications, signal functions and how to
treat them
3. Describe PAC and programming issues
4. Explain EmOC indicators
Minimum Initial Service Package (MISP) for RH in Crisis Situations
Objective 1
Identify agency/persons to facilitate
COORDINATION & IMPLEMENTATION
◙ RH coordinator in place under health
coordination team
◙ RH focal person in place in camps
◙ RH kits available & used
RH Kit
0
Objective 5
Plan for COMPREHENSIVE RH services,
integrated into Primary Health Care
◙ Baseline info & M&E
◙ ID sites for future delivery of comprehensive RH
◙ Assess staff & ID training protocols
RH Kit
4
RH Kit
5
RH Kit
7
Mortality, morbidity & disability
in crisis-affected populations
(refugees/IDPs or populations
hosting them)
Objective 4
Prevent EXCESS maternal & neonatal mortality
& morbidity
◙ Referral system for EmONC available 24/7
RH Kit ◙ Midwife delivery kits for clean and safe
6
deliveries @ health facilities
◙ Provide clean delivery kits for visibly
RH Kit pregnant women & birth attendants
to ensure clean home deliveries
2
RH Kit
8
RH Kit
9
RH Kit
10
Prevent sexual violence & assist survivors
◙ Protection system in place for displaced
populations, especially women & girls
GOAL
◙ Procurement channels
RH Kit
11
RH Kit
12
Objective 2
◙ Medical services & psychosocial support
available for survivors
RH Kit
3
RH Kit
9
Objective 3
Transmission of HIV/STI
◙ Universal precautions enforced
◙ Free condoms available
◙ Safe blood transfusion
RH Kit
1
Universal precautions
through kits 1-12
RH Kit
12
Worldwide
Worldwide per
per year:
year:
358,000
358,000 maternal
maternal deaths
deaths
44 million
million newborn
newborn deaths
deaths
Maternal Mortality Ratio worldwide,
2008
Why is maternal mortality so
stubbornly high?
• Approximately 15% of all pregnant women
develop complications
• Most direct obstetric complications cannot be entirely predicted or prevented • BUT: Most maternal deaths are caused by direct obstetric complications that can be treated
Causes of maternal death
(WHO: The World Health Report 2005: Making Every Mother and Child Count)
Time… is not on our side
Time to death:
•
•
•
•
•
•
Postpartum hemorrhage 2 hours
Antepartum hemorrhage 12 hours
Ruptured uterus
1 day
Eclampsia
2 days
Obstructed labor
3 days
Infection
6 days
Neonatal mortality rate
2000
Newborn deaths per 1,000 live births, 2000
Causes of newborn death
(IAFM: 2009)
When newborns die
50% occur in the
first 24 hours
Asphyxia
75% occur in the
first week
(3 million)
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Preterm/LBW
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Three Core Life Saving Strategies for
Reducing Maternal Mortality
1. Family planning
2. Skilled Birth Attendance
3. Emergency obstetric care
(Access to a highly skilled provider with resources who can manage the most common complications)
Why isn’t ANC a core strategy for
maternal survival?
• Because most complications during pregnancy and
delivery CANNOT be predicted.
• Traditional ANC focused on screening women for “risk
factors” (too old, too many, too short) that would predict
a problem pregnancy/delivery
•
MOST complications occurring in women with NO risk
factors.
• Take home message: complications occur in ALL women
(with risk factors as well as no risk factors), and they
develop often unexpectedly and quickly
Birth Planning
•
Plan for place for routine birth:
Know and Plan for immediate, essential care for baby:
• Warmth
• Cleanliness and clean cord care
• Immediate breast feeding
„ Recognize danger signs: WHAT are they?
„ Plan for unexpected problems:
WHERE, WHO, HOW, $$
Essential vs Emergency
• Essential Obstetric and Newborn Care
– refers to a broad range of standard
interventions used by skilled providers during
routine (normal), uncomplicated childbirth
and newborn care
• Emergency Obstetric Care/ EmONC
– Prioritized life-saving interventions based on
leading causes of maternal and neonatal
mortality
Review of the MISP
EmOC signal functions
Life-saving interventions that address the
most common causes of maternal death:
•
•
•
•
•
Hemorrhage
Sepsis
Prolonged or obstructed labor
Complications of abortion
Severe pre-eclampsia / eclampsia
Signal functions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Administer parenteral antibiotics
Administer parenteral uterotonics
Administer parenteral anticonvulsants
Perform manual removal of the placenta
Perform removal of retained products of conception
Perform assisted vaginal delivery
Perform neonatal resuscitation
Perform surgery under anesthesia
Perform safe and rational blood transfusion
Manual removal of placenta
Perform manual removal of the placenta
Removal of retained products
MVA for removal of retained products of
conception
Assisted vaginal delivery
Perform assisted vaginal delivery
Newborn resuscitation
Perform newborn resuscitation
Beck D., et al. Care of the Newborn: Reference Manual. 2004, Save the
Children.
Basic vs. comprehensive
EmOC
A basic EmONC facility has performed each of the
following signal functions at least once within the
previous 3 months:
1. Administer parenteral antibiotics
2. Administer parenteral uterotonics
3. Administer parenteral anticonvulsants
4. Perform manual removal of the placenta
5. Perform removal of retained products of
conception
6. Perform assisted vaginal delivery
7. Perform neonatal resuscitation
Basic vs. comprehensive
EmOC
A comprehensive EmOC facility has
performed each of the following signal
functions at least once within the previous 3
months:
1. Signal functions 1-7 above, PLUS
2. Perform cesarean and laparotomy under
anesthesia
3. Perform blood transfusion
Referral Systems
• Early
recognition of
danger signs at
community and
primary health
care center
• Communication
• Transportation
system
Emergency Obstetric
Care (EmOC)
BEmOC and CEmOC
facilities must be:
•appropriately staffed
and equipped
•available 24 / 7
Preparation Stage
Service Delivery Stage
EmOC Building Blocks Framework
Utilization
On-site
QI Process
On-going
Readiness
Training
Renovation
&
Maintenance
External
Supervision
24/7
EmONC
Team
Building
Staffing
Supplies
& Equipment
EmOC Needs
Facility
Setup
Assessment
Data
Collection
Monitoring EmOC
EmOC programs must:
• Exist and function
• Be geographically and equitably distributed
• Be used by pregnant women
• Be used by women with complications
• Provide sufficient and timely life-saving
services
• Provide good-quality care
(WHO: Monitoring Emergency Obstetric Care: a Handbook, 2009)
EmOC Indicators
Indicator
Acceptable level
1. Availability of EmOC: BEmOC and CEmOC
facilities
At least 5 EmOC facilities (including at least 1 CEmOC facility)
for every 500,000 population
2. Geographic distribution of EmOC facilities
All sub-national areas have at least 5 EmOC facilities (including
at least 2 CEmOC facility) for every 500,000 population
3. Proportion of all births in EmOC facilities
(minimum acceptable level to be set locally)
4. Meeting the need for EmOC: proportion of
women with major direct obstetric
complications who are treated in such facilities
100% of women estimated to have major direct obstetric
complications are treated in EmOC facilities
5. Cesarean sections as a proportion of all
births
The estimated proportion of births by cesarean section in the
population is not less than 5% or more than 15%
6. Direct obstetric case fatality rate
The case fatality rate among women with direct obstetric
complications in EmOC facilities is less than 1%
7. Intrapartum and very early neonatal death
rate
Standards to be determined
8. Proportion of maternal deaths due to indirect
causes in EmOC facilities
No standard can be set
(WHO: Monitoring Emergency Obstetric Care: a Handbook, 2009)
Calculating EmOC Indicators
During MISP implementation, priority is given to
ensuring that quality services are available 24/7
• Indicators are measured at the facility (or
camp) level during an acute emergency.
Scale-up to measure indicators at the
regional level, once situation stabilizes
• Data collection tools may need to be updated
to capture data required to calculate UNPI
You have data, now what??
Group Exercise
Misoprostol
• Prostaglandin E1 analog registered for
prevention/treatment gastic ulcers
• Induces uterine contractions: "off-label"
• Broad range of RH use
– indication, gestational age, dose, route
• Importance of evidence updates, data
collection, monitoring
• Product Pathway
Misoprostol: WHO Position
• Included in evidence-based guidelines and
Model List of Essential Medicines for
– early pregnancy termination (with mifepristone)
– medical management of miscarriage
– labour induction
• PPH prevention recommendation:
– "In the absence of AMTSL, a uterotonic drug
(oxytocin or misoprostol) should be offered by a
health worker trained in its use"
WHO Guidelines Production Process Beginning
1
A WHO department decides to produce a guideline
End
2
3
Initial approval by GRC
Initial approval for development The guideline is produced by the WHO department (i.e. from a few months to 2‐3 years time frame)
4
5
Final
approval by GRC
Relevant approvals are obtained (ADG or DGO)
GRC Secretariat throughout the process of production of a guideline, the WHO department can access the resources provided by the GRC Secretariat
Advice and support from the GRC Secretariat
Advice and support from members of the GRC Advice and support from WHO Collaborating Centres
Advice and support from GRC through WHO lists of technical experts Advice and support from external experts on guideline production Guideline Development Process 1
2
3
4
5
Scoping the document Setting up Guideline Development Group and External Review Group Management of Conflicts of Interest
Initial guideline approval
• After completion of 1 and 2
• With draft of 4
• With plan for 3, 5‐9 Formulation of the questions (PICOT) and choice of the relevant outcomes
Evidence retrieval, assessment and synthesis (systematic review(s)
GRADE ‐ evidence profile
6
Formulation of the recommendations (GRADE)
Including explicit consideration of: ~ Benefits and harms
~ Values and preferences ~ Resource use
7
Final guideline approval
•after completion of 6
Dissemination, implementation (adaptation)
8
Evaluation of impact 9
Plan for updating •with plan for 7‐9 Abortion Worldwide
• 42 million pregnancies end in abortion
– 20 million of these are unsafe
• Unsafe abortion results in 13% of maternal
deaths
– 99% of these are in developing countries
Women and girls in humanitarian settings
are at increased risk of unintended
pregnancy and unsafe abortion
Post Abortion Care (PAC)
•
•
•
•
•
Treatment of incomplete and unsafe
abortion
Counseling to identify women’s needs
Contraceptive and family planning
services
Reproductive and other health services
Community and service provider
partnerships
Postabortion Care
PAC includes:
• Prevention
• Treatment
• Counseling and services to respond to SRH needs and concerns
Five essential elements:
1. Community and service provider partnerships for prevention (of unplanned
pregnancies and unsafe abortion);
2. Counseling to identify and respond to women's emotional and physical health
needs and other concerns;
3. Treatment of incomplete and unsafe abortion and complications that are
potentially life-threatening;
4. Contraceptive and family planning services to help women prevent an unplanned
pregnancy or practice birth spacing; and
5. Reproductive and other health services that are preferably provided on-site or via
referrals to other accessible facilities in providers' networks.
Uterine evacuation:
Vacuum aspiration
• Manual vacuum aspiration (MVA)
• Effective through 12 weeks gestation
• Examine POCs to rule out ectopic or molar
pregnancy and incomplete abortion
• Local anesthesia and/or ibuprofen
minimum pain requirements
MVA for PAC
Perform removal of retained products of
conception
Manual vacuum aspiration (MVA) kit
Postabortion Care
• Both vacuum aspiration and misoprostol
are safe and effective for uterine
evacuation
• Misoprostol cheaper and may be easier in
humanitarian settings
• Misoprostol regimen for incomplete
abortion up to 12 weeks gestation
– 600mcg misoprostol orally x 1
Post-abortion contraception
• Ovulation can occur 10 days after an
abortion
• Contraception acceptance and
continuation rates are higher when offered
at time of the abortion
• Immediate insertion of IUD or start of ther
methods of contraception are safe
Medical Abortion
• Highly effective through 9 weeks gestation
• Preferred regimen: Mifepristone and Misoprostol
– Mifepristone 200mg, followed after 24-48hr by
Misoprostol 800mcg pv or sublingually
– 95-99% efficacy
• Misoprostol alone: 800mcg pv or sublingually
repeated every 12h x 3 doses max
– 85-90% efficacy
Indicators for PAC
Infection prevention
see EngenderHealth Manual
Standard Precautions:
• Wash your hands – routine with soap and running water, with
antiseptics and running water for invasive procedures, and alcohol
handrub when water is unavailable
• Wear gloves whenever coming in contact with blood and body fluids
• Wear eye protection or faceshields and gowns when there is a risk
of splashing
• Prevent injuries from contaminated sharps and needles
• Correctly process instruments and client-care equipment
• Maintain correct environmental cleanliness and waste-disposal
practices
• Handle, transport and process used/soiled linens correctly
Infection Prevention
Disposing of sharps:
• Dispose of needles and syringes
immediately after use in a puncture
• Resistant sharps disposal container
• Do not fill the container more than threequarters full
• Incinerate sharps disposal container
• Incinerators or burial in closed pits per
protocol
Infection prevention
Antiseptics
• What are antiseptics?
• Chemical agents that decrease microorganisms on skin
and mucus membranes without irritation or damaging
tissues
• Use:
– Before clinical procedures
– For surgical scrub
– For handwashing in high risk situations
Infection prevention
Disinfectants:
• What are disinfectants?
• They kill microorganisms on inanimate objects, such as
surfaces, e.g. floors, countertops and examination tables
• Use:
– Decontamination
– Chemical High Level Disinfection (HLD)
– Housekeeping
Infection prevention
Autoclaving:
• Main form of sterilization
• All viruses including HIV are inactivated by
autoclaving for 20 minutes at 121 – 131 degrees
Celsius (30 minutes if instruments in wrapped
packs)
• More practical to use a small autoclave several
times a day than to use a large machine once
• At end of procedure, outside of packs of
instruments should have no wet spots which
may indicate that sterilization has not occurred
Insert file name 50
Why
?
Why does
does maternal
maternal and
and newborn
newborn health
health matter
matter?
Austria: 5
Sweden: 5
Spain: 6
Somalia:
1200
Chad:
1200
Afghanistan: 1400
Emergency Response Phases
Development/
Preparedness
Preparedness
EPP MISP
Acute
MISP
for RH
Post acute
Post acute
(can be chronic)
(can be chronic)
MISP &
comprehensive
RH
Rehabilitation/
Rehabilitation/
Reconstruction
reconstruction
/ Development
MISP &
comprehensive
RH
MOH, Implementing partners, Humanitarian Reform Clusters and working groups
Disaster Risk Reduction
Increasing
Increasing access
access to
to preventive
preventive and
and
treatment
treatment options
options in
in low
low resource
resource settings
settings
garment for postpartum haemorrhage
• Incubator development
• Odon device
• Funnel
Insert file name 53
• Antishock